Injury
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In multiply injured patients with major blunt thoracic injuries, the continued high mortality is mainly caused by the additive effect of the unstable flail chest associated with pleural and lung injuries upon the pulmonary gas exchange disturbance caused by haemorrhagic shock. A more active approach with early thoracotomy and chest wall stabilization is recommended. Three groups of injuries provide the appropriate indication: 1. ⋯ In all cases the thoracotomy should be performed after resuscitation of the patient on the day of the accident or within 3 days. Screwless elastic self-clasping rib plates were used in 15 multiply injured patients and in 5 isolated thoracic cases with good results and a low complication rate. The mortality was reduced from 64 per cent to 36 per cent in the patients with multiple injuries.
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Heat necrosis of bone is described after the insertion of Steinmann or Denham pins using a powder drill, in four patients. Troublesome infection developed in all of these patients and fracture occurred through the pin site in two. Block excision of the affected area appears to have eradicated the infection in three patients. One an did not require operation.
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The advantages of the Ender technique over the other methods of treatment of trochanteric fractures of the femur have been emphasized by several authors but the difficulties and complications of the method have perhaps not been sufficiently highlighted. With this imbalance in mind, 60 patients treated by the Ender method have been reviewed with particular emphasis on the problems encountered during treatment. ⋯ The main postoperative complications were the cutting out of the nails from the head and neck fragment with weight bearing, backing down of the nails at the knee, and external rotation deformity. The early mortality, infection, delayed union and non-union rates were low.
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Case Reports
Penetrating left ventricular stab wound: a method of control during resuscitation and prior to repair.
A 34-year-old man with left ventricular stab wounds, suffered cardiac arrest soon after arriving in the Intensive Care Unit from the Accident and Emergency Department. He had cardiac tamponade without elevation of his central venous pressure; this was because of exsanguination into his left hemithorax. Immediate thoracotomy while still in his bed confirmed tamponade and revealed two large left ventricular stab wounds, one anterior and on posterior; the heart was in ventricular fibrillation. ⋯ This was achieved by inserting a Foley catheter into each wound, inflating the balloons, clamping the catheters and having the assistant gently retracting the catheters against each other while the operator continued with the resuscitation. When the circulation was restored, pledgeted horizontal mattress sutures were inserted on either side of each Foley catheter, which was withdrawn immediately before tying the suture. The patient was discharged home 12 days later without any complications.
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The effect of legislation for the compulsory wearing of seat belts by car drivers and front seat passengers was prospectively analysed in the county of Skaraborg, Sweden. After legislation fewer vehicle occupants were admitted to the hospitals, depsite a 40 per cent increase in crashes reported to insurance companies in the country. The frequency of seat belt wearing among injured victims was considerably lower than that recorded in regular traffic surveys. ⋯ Restrained front seat passengers had more thoracic injuries than unrestrained, but the degree of severity was less. The frequency of seat belt wearing by rear seat passengers was low, but they were injured as severely as front seat occupants. It seems important to insist on an increase in seat belt wearing for this category.